<ul><li><p>Revision Anterior Cruciate Ligament Reconstruction with Doubled Semitendinosus and Gracilis Tendons and Lateral Extra-Articular Reconstructionby Andrea Ferretti, Fabio Conteduca, Edoardo Monaco, Angelo De Carli, and Carmelo D'ArrigoJ Bone Joint Surg AmVolume 89(2 suppl 2):196-213September 1, 20072007 by The Journal of Bone and Joint Surgery, Inc.</p></li><li><p>Preoperative lateral (left) and anteroposterior (right) radiographs showing a failed anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft.Andrea Ferretti et al. J Bone Joint Surg Am 2007;89:196-2132007 by The Journal of Bone and Joint Surgery, Inc.</p></li><li><p>T1-weighted magnetic resonance image of a failed anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft. Andrea Ferretti et al. J Bone Joint Surg Am 2007;89:196-2132007 by The Journal of Bone and Joint Surgery, Inc.</p></li><li><p>Extensive bone loss due to convergence of tibial tunnels is managed with Evolgate fixation and grafting: A: bone loss; B: the Evolgate device (Citieffe, Bologna, Italy); C: preparation for Evolgate insertion; and D: Evolgate inserted with tendon passage. Andrea Ferretti et al. J Bone Joint Surg Am 2007;89:196-2132007 by The Journal of Bone and Joint Surgery, Inc.</p></li><li><p>Failure of anterior cruciate ligament reconstruction due to an anteriorly placed femoral tunnel. Andrea Ferretti et al. J Bone Joint Surg Am 2007;89:196-2132007 by The Journal of Bone and Joint Surgery, Inc.</p></li><li><p>Andrea Ferretti et al. J Bone Joint Surg Am 2007;89:196-2132007 by The Journal of Bone and Joint Surgery, Inc.</p></li><li><p>Andrea Ferretti et al. J Bone Joint Surg Am 2007;89:196-2132007 by The Journal of Bone and Joint Surgery, Inc.</p></li><li><p>Positioning of the patient on the operating table. Andrea Ferretti et al. J Bone Joint Surg Am 2007;89:196-2132007 by The Journal of Bone and Joint Surgery, Inc.</p></li><li><p>Location of the central transtendinous arthroscopic portal.Andrea Ferretti et al. J Bone Joint Surg Am 2007;89:196-2132007 by The Journal of Bone and Joint Surgery, Inc.</p></li><li><p>Intra-articular view of a failed anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft due to graft elongation. Andrea Ferretti et al. J Bone Joint Surg Am 2007;89:196-2132007 by The Journal of Bone and Joint Surgery, Inc.</p></li><li><p>Removal of an interference screw with an arthroscopic grasper.Andrea Ferretti et al. J Bone Joint Surg Am 2007;89:196-2132007 by The Journal of Bone and Joint Surgery, Inc.</p></li><li><p>Localization of atibial fixation device with the aid of fluoroscopy.Andrea Ferretti et al. J Bone Joint Surg Am 2007;89:196-2132007 by The Journal of Bone and Joint Surgery, Inc.</p></li><li><p>Semitendinosus tendon stripping.Andrea Ferretti et al. J Bone Joint Surg Am 2007;89:196-2132007 by The Journal of Bone and Joint Surgery, Inc.</p></li><li><p>Lateral hockey-stick incision.Andrea Ferretti et al. J Bone Joint Surg Am 2007;89:196-2132007 by The Journal of Bone and Joint Surgery, Inc.</p></li><li><p>The iliotibial tract is incised along its fibers (A), after which the vastus lateralis is retracted, exposing the lateral femoral condyle (B).Andrea Ferretti et al. J Bone Joint Surg Am 2007;89:196-2132007 by The Journal of Bone and Joint Surgery, Inc.</p></li><li><p>Tendons mounted on the workstation.Andrea Ferretti et al. J Bone Joint Surg Am 2007;89:196-2132007 by The Journal of Bone and Joint Surgery, Inc.</p></li><li><p>Reamings from the drill are collected and used for grafting.Andrea Ferretti et al. J Bone Joint Surg Am 2007;89:196-2132007 by The Journal of Bone and Joint Surgery, Inc.</p></li><li><p>Andrea Ferretti et al. J Bone Joint Surg Am 2007;89:196-2132007 by The Journal of Bone and Joint Surgery, Inc.</p></li><li><p>Andrea Ferretti et al. J Bone Joint Surg Am 2007;89:196-2132007 by The Journal of Bone and Joint Surgery, Inc.</p></li><li><p>The Evolgate device is composed of three titanium-alloy components: a coil (a spiral 21 mm in length and 10 mm in diameter) with a spike positioned at one extremity, a 9 20-mm screw, and a washer. Andrea Ferretti et al. J Bone Joint Surg Am 2007;89:196-2132007 by The Journal of Bone and Joint Surgery, Inc.</p></li><li><p>A, B, and C: Insertion of the coil of the Evolgate (Citieffe) in the bone tunnel.Andrea Ferretti et al. J Bone Joint Surg Am 2007;89:196-2132007 by The Journal of Bone and Joint Surgery, Inc.</p></li><li><p>The Swing-Bridge (Citieffe) device consists of a titanium-alloy cylinder (diameter, 10 mm) with a smooth metal half-ring (diameter, 10 mm) at one end and a shelf with grooves at the other. Andrea Ferretti et al. J Bone Joint Surg Am 2007;89:196-2132007 by The Journal of Bone and Joint Surgery, Inc.</p></li><li><p>Final fixation with screw and washer.Andrea Ferretti et al. J Bone Joint Surg Am 2007;89:196-2132007 by The Journal of Bone and Joint Surgery, Inc.</p></li><li><p>Andrea Ferretti et al. J Bone Joint Surg Am 2007;89:196-2132007 by The Journal of Bone and Joint Surgery, Inc.</p></li><li><p>Andrea Ferretti et al. J Bone Joint Surg Am 2007;89:196-2132007 by The Journal of Bone and Joint Surgery, Inc.</p></li><li><p>Andrea Ferretti et al. J Bone Joint Surg Am 2007;89:196-2132007 by The Journal of Bone and Joint Surgery, Inc.</p></li><li><p>Andrea Ferretti et al. J Bone Joint Surg Am 2007;89:196-2132007 by The Journal of Bone and Joint Surgery, Inc.</p></li><li><p>Andrea Ferretti et al. J Bone Joint Surg Am 2007;89:196-2132007 by The Journal of Bone and Joint Surgery, Inc.</p><p>Preoperative lateral (left) and anteroposterior (right) radiographs showing a failed anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft.T1-weighted magnetic resonance image of a failed anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft. There is severe enlargement of the tibial tunnel, suggesting the possible need for a two-stage procedure.Extensive bone loss due to convergence of tibial tunnels is managed with Evolgate fixation and grafting: A: bone loss; B: the Evolgate device (Citieffe, Bologna, Italy); C: preparation for Evolgate insertion; and D: Evolgate inserted with tendon passage. Note filling of the tunnel with bone graft (small arrows) from the site of bone harvesting (large arrow).Failure of anterior cruciate ligament reconstruction due to an anteriorly placed femoral tunnel. Postoperative anteroposterior (left) and lateral (right) radiographs showing the new femoral tunnel and device divergent from the preoperative femoral tunnel, with the old device remaining in situ.Positioning of the patient on the operating table. The position of the leg holder and sandbag allows the leg to be supported during the procedure and to be freely taken through a complete range of motion.Location of the central transtendinous arthroscopic portal.Intra-articular view of a failed anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft due to graft elongation. The arrow indicates the absorbable interference screw.Removal of an interference screw with an arthroscopic grasper.Localization of atibial fixation device with the aid of fluoroscopy.Semitendinosus tendon stripping.Lateral hockey-stick incision.The iliotibial tract is incised along its fibers (A), after which the vastus lateralis is retracted, exposing the lateral femoral condyle (B).Tendons mounted on the workstation.Reamings from the drill are collected and used for grafting.The Evolgate device is composed of three titanium-alloy components: a coil (a spiral 21 mm in length and 10 mm in diameter) with a spike positioned at one extremity, a 9 20-mm screw, and a washer. Before the tendons are pulled through the tibial tunnel, the spiral is inserted into the tibial tunnel with a special impactor, which also provides penetration of the spike in the predrilled tibial cortex. After the tendons are pulled through the bone tunnels and secured at the femoral side, the four tendon ends coming out of the tibial tunnel are properly tensioned. The screw and the washer are then inserted, interfering with the tendons and the spiral, until the washer presses against the tibial cortex. The spike prevents rotation of the spiral as the screw tightens. (Reprinted, with permission, from: Ferretti A, Conteduca F, De Carli A, D'Arrigo C. Revision anterior cruciate ligament reconstruction with doubled semitendinosus and gracilis tendons and lateral extra-articular reconstruction. J Bone Joint Surg Am. 2006;88:2373.)A, B, and C: Insertion of the coil of the Evolgate (Citieffe) in the bone tunnel.The Swing-Bridge (Citieffe) device consists of a titanium-alloy cylinder (diameter, 10 mm) with a smooth metal half-ring (diameter, 10 mm) at one end and a shelf with grooves at the other. The free tendon ends are threaded through the ring of the device and then pulled into the joint with use of an outside-in technique. With an impactor, the cylinder is completely inserted into the femoral tunnel until the shelf reaches the femoral cortical bone. In the case of loss or improper tension of the graft after tibial fixation, the Swing-Bridge allows a second and final tensioning of the graft, which can be accomplished by twisting the graft bundles from the femoral side. (Reprinted, with permission, from: Ferretti A, Conteduca F, De Carli A, D'Arrigo C. Revision anterior cruciate ligament reconstruction with doubled semitendinosus and gracilis tendons and lateral extra-articular reconstruction. J Bone Joint Surg Am. 2006;88:2374.)Final fixation with screw and washer.</p></li></ul>